Cervical Incompetence

Incidence and Prevalence Definition Inability of the uterine cx to retain a pregnancy in the absence of contractions or labor Incidence and Prevalence The lack of objective findings and clear dx criteria makes the incidence of CI difficult to ascertain

Risk Factors Congenital Acquired Congenitally short Cx Trauma Mullerian duct abnormalities Cx laceration following SVD Prolonged 2nd stage of labor Deficiencies in Cx collagen & elastin Surgical Procedures involving the Cx (D&C, Cone bx) Uterine over distention (multiple gestation, Polyhydramnios)

Clinical Manifestations ► The classic presentation of CI is: Cx dilatation and effacement in the 2nd trimester with fetal membranes visible at or beyond the external os in the absence of contractions. Which maybe asymptomatic or associated with: Vaginal fullness or pressure Spotting or bleeding An ↥ volume of watery, mucousy or brown VD Vague discomfort in the lower abdomen or back (sonographic manifestations of CI often occur prior to clinically detectable Cx changes)

Diagnosis Non-Pregnant women Pregnant women • There are no tests which can be performed to predict CI in a future pregnancy. • Those that have been proposed are inaccurate, inconvenient, or unproven in scientific studies • This may be based upon historical, clinical or sonographic criteria (non has been validated in well designed studies)

Pregnant women Historical features of CI Hx of two or more 2nd trimester pregnancy losses Hx of losing each pregnancy at an earlier gestational age Hx of painless Cx diltation of up to 4-6 cm Absence of clinical findings consistent with placental abruption Hx of Cx trauma caused by Cone bx Intrapartum Cx lacerations Excessive, forced Cx dilatation during TOP Harger JH. An evidance based analysis. Obstet Gynecol 2002;100:1313-27 (level II-2) Diagnosis

Pregnant women Clinical criteria A digital examination should always be performed to evaluate the Cx in cases of CI, followed by TVS if the clinical examination is not diagnostic Clinical findings include → significant premature Cx effacement and/or dilatation (> 2cm) specially with prolapse of fetal membranes into or completely through the endocervical canal (hourglassing) Diagnosis

Pregnant women Sonographic features • US of the Cx is more accurate and reproducible than D/E • The most consistent image of the Cx is obtained by TVS performed at ≥ 16 wks • Noninvasive stress techniques as : transfundal pressure, coughing and standing have been used to elicit US Cx changes • Serial US assessment of Cx length in women between 24-28 wks has been correlated with PTD Iams, JD, Goldenberg, RL, Meis, PJ, et al. N Engl J Med 1996; 334:567(level II-2) Diagnosis

Treatment approaches Non-surgical modalities Surgical (cerclage) Modified activity Bed rest Pelvic rest IM hydroxyprgesteron Vaginal pessaries Have not achieved wide spread acceptance and have not yet been proved to be effective The rational for surgery is that cerclage compensate for inherent Cx weakness & the only indication is the prevention of CI during pregnancy Cx cerclage is the standard treatment for CI, despite little data from randomized trials proving efficacy Newcomer J. Ostet Gynecol Surv 2000; 55:443-8. (level III) MRC/RCOG Working Party on Cervical Cerclage. Br J Obstet Gynaecol 1993; 100:516 (level I). Lazar, P, Gueguen, S, Dreyfus, J, et al. Br J Obstet Gynaecol 1984; 91:731. (level I)

Contraindications to Cerclage Maternal factors: Premature labor Premature rupture of membranes Abruption of placenta Intraamniotic, cervical, or vaginal infection Medical condition that precludes administration of anesthesia or continuation of pregnancy Fetal factors: Fetal demise Fetal anomaly incompatible with extrauterine life Nonreassuring fetal status GA > 24 to 28 wks Treatment approaches Surgical

Cervical Cerclage Procedure Objective Transvaginal Transabdominal To reinforce the Cx at the level of the internal os; a 2ry effect is to lengthen the Cx Transvaginal Transabdominal Treatment approaches Surgical

Treatment approaches Surgical

Cervical Cerclage Transvaginal McDonald: a purse-string suture placed around the Cx as cephalad as possible & without dissection of the bladder or rectum. Treatment approaches Surgical

Cervical Cerclage Transvaginal Shirodkar: is performed using a 5 mm Mersilene tape placed around the Cx at the level of the internal os after surgically reflecting the UB anteriorly & the rectum posteriorly. Treatment approaches Surgical

Cerclage removal The cerclage is removed electively at 37 to 38 weeks or immediately with the onset of premature labor to avoid cervical laceration and/or uterine rupture Whether to remove the cerclage in the setting of PPROM is controversial A Shirodkar cerclage does not have to be removed if cesarean delivery is anticipated and future pregnancies are planned Treatment approaches Surgical

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